Viral Hepatitis E (HEV) - Final note (Part 6)

Today I am reading a book of memoir by Lee  Kuan Yew, a glowing example of leadership (my understanding)  - the name of the book is "From Third World to First" and this thick book of almost 800 pages walks you through the Singapore's story of success from 1965 to 2000. Fortunately, I had a chance to be in Singapore on the day of his farewell march for eternity. I could see how much people of Singapore adore and respect him. From the unending line of people waiting patiently in that tropical heat was a sight that we have "so rare" a chance to witness. No doubt, he has contributed so much to bring Singapore from nothing to one of the economic power house in South East Asia. You may be wondering why I am talking about Mr, Lee and what does he have to do with theme of this series? Well, I know, it may sound way opposite but from the story of Mr. Lee what am i trying to understand is what we can do and learn from him in order to make things happen !! For this, i think, he deserves attention and we seriously contemplate on his wisdom so we also can also do the most from what we have and make the best use of time and resources. That is it !! I dedicate this final note to Mr. Lee and this is all i can do to understand his contribution in terms of learning and educating ourselves in making things happen instead of just complaining about existing adversaries.

With this, I read Chapter 49 of Plotkin's Vaccine on Hepatitis E vaccine. There are few facts i need to write for my memory and keeping facts straight before i conclude this series for next one. Here follows some facts on HEV:

• Incubation period (IP) is approximately 40 days
• most important acute viral hepatitis among adults in much of central and southeastern  Asia and the Indian Subcontinent and the second most important hepatitis in the Middle east and North Africa
• Up to 20 % clinical attack rate and an associated high incidence of fetal wastage
• In endemic countries, genotypes 1 and 2 predominate and contaminated water is the major source of infection.
• Seronegative children and adults are at general risk of disease and pregnant women are at special risk for severe or fulminant hepatitis in endemic regions
• With regards to vaccination - HEV vaccination is best suited to be included in EPI schedule rather than providing this vaccine in campaign mode. 

Finally, my intention of writing this HEV series is primarily for self understanding and share my thoughts to wider interest group who has interest to involve in this line of work. I know, this is a drop in ocean but you never know how important that a single drop can contribute in better understanding of the disease where it is so important as a public health problem. My opinion is that we need to strengthen our own capability and network and bring the necessary preventive measures to the community rather than waiting for some outside agencies. 

Action items:

1. Review paper
2. Explore partnership and make things happen with clarity in work plan

28 March 2015

Viral Hepatitis E (HEV) series & Nepal - Nitty Gritty of HEV !!! (Part 5)

To provide general sense of geographical location and socioeconomic landscape, i am going to walk  you all through a short narrative on Nepal. 

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Nepal is a land-locked country having geographical and cultural proximity to the Ganges plain and comprises of 3 ecological zones: Mountain, Hills and Terai. The population is approximately 29.8 million as of 2014 with the density being highest in the Terai region followed by mid – hills. Nepal is ranked 157^th among 187 countries in Human Development Index report (HDI - 2013).  The total percentage expenditure on health out from Gross National  Product (GNP) is 5.8 % and of which the expenditure on public health sector is only 2.0 %. As of now, the trend of expenditure on health sector  is not encouraging due to socio - political instability of the country. 

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With this background, I think, you can get a visual picture how common Nepali people must be living their life in rural impoverished community. Well, some month ago, when i wrote a brief note on cholera outbreak in some remote part of Terai, I got a public comment that it is not what i depicted in my writing. But we can hide the fact that there was an outbreak of significant impact in the communities. This we can not deny and I hope one of my friend could be in a position to acknowledge that there exist challenges in clean water and sanitation delivery to the much needed people. However, we can debate on this public health issue. It can be controversial for those leaving in affluence. 

Recently, I am short of words or even an idea to write on HEV issues. It is  primarily because of a silent or deaf response to what i have been trying to communicate re: the issue and what we can do in Nepal? I will not go into this now, but since this is only with me i will vomit out once i find it rationally reasonable to share to the reader how politics and even distinction play a role in academic field based on your nationality. This is painful to each of us. I hope other side realize this, sometime at right moment i will be vocal about it. 

Nonetheless, I have to write and this is the only way we can thrive in this global health arena. Coming to subject - HEV is an area that needs much advocacy from the community and national level like Nepal / India / Ethiopia, where HEV is still serious public health issue. We should not wait for it instead we need to advocate to the global health community. This is what i have been saying we should work simultaneously from both end - at international fora as well build base at the community level and have find a meeting point where international authorities and community health leaders can sit together and have a meaningful but fruitful outcome from all the penny invested in such study re: HEV or any other vaccines.

I think, i have shared enough about HEV outbreaks in Nepal. Now, at my personal level, a concrete research concept is what is the need of the hour along with active collaboration with academician and public health professionals in Nepal. For this, we need to review papers so far published re: HEV in Nepal and find out knowledge gaps where we need to address. Also, the key to what we plan can only be successful if we partner with international organizations, who can advocate on this problem at an international fora. 

Therefore, this planned review (that we need to write) has to bring out the comprehensive HEV epidemiology in Nepal. It should also incorporate opinion from all stakeholders, who has a role to play in bringing this much needed vaccine to the community. So following points have to be raised pretty well in the paper. And this can be an advocacy paper of much public health significance [period]

• Explain  location  / nos. / distribution/seasonality of HEV in Nepal
• Possibly - mapping of outbreaks (raw sketch)
• Virus - its form and its characteristics
• Players in HEV studies in Nepal
• Important area of concern - public health /vaccine development perspective

Finally, I have already written much in my previous posts that there is a huge demand for HEV vaccine in countries like Nepal, Ethiopia, India, Myanmar. This has been spelled out by leading physicians and researchers in Nepal as well. The only remaining challenge is whether the voice of demand for HEV vaccine has reached those who invest or has resources to focus available fund in this area or not? I think, it has reached and it all lie within us how efficiently advocate on this HEV issue at national or international level. Importantly, I believe we have to raise awareness in the national as well as community level..

22 March 2015